C-11-212 Address Request to Add an Out-of-State Provider in HCHB

👤 RESPONSIBLE POSITION  |  ROLE

Medical Records Specialist

🎯 PURPOSE

This process provides the steps which need to be completed by the Medical Records Specialist to determine whether an out-of-state provider is able to sign home health orders or the Face to Face Encounter (F2F) for a home health client.

Whenever an out-of-state provider is identified, the case must be reviewed individually to determine whether the provider is eligible to be used in the specific situation.

🔄 PROCESS

  1. When Medical Records Specialist discovers or is notified that the provider is an out-of-state provider (not licensed in Minnesota), they will follow this process.
  2. Ensure the provider is not licensed in the state of Minnesota as either a physician or qualifying non-physician practitioner.
    • If they are licensed in Minnesota, this process does not apply.
  3. Verify the out-of-state licensure for the provider with that state board. Ensure their license is active and valid.
    • Typically, the NPI Registry listing for the provider will give an indication of the provider's state of licensure.
  4. Verify PECOS status for the provider by completing the following:
    1. Navigate to the CMS PECOS verification website (data.cms.gov).

    2. On the CMS website, scroll down and select Order and Referring.

    3. Select View Data.

    4. Enter the physician/NPP's NPI or last name and search. If PECOS is verified for home health agencies, there will be a Y under the HHA column.
    5. If the physician/NPP is not PECOS-verified (indicated by a N under the HHA column):
      • Review the payer selection to ensure a Medicare or Medicare Advantage payer is not set up as PRIMARY, SECONDARY or TERTIARY.
      • If there is a Medicare or Medicare Advantage payer set up as PRIMARY, SECONDARY or TERTIARY, notify the branch that the provider is not PECOS-verified. Ask the branch whether they would like to proceed or not (knowing they cannot bill a Medicare payer if they use this provider).
  5. Verify that the provider is enrolled with Medicaid.

    1. Log into the MN-ITS website: https://mn-its.dhs.state.mn.us/gatewayweb/login

      Select Provider Lists from the menu on the left-hand side.  

      Select the Ordering/Prescribing Providers file.

      The list of providers will download to your browser. Select the document from your downloads.

      • NOTE: Always access this document from the MN-ITS website to ensure you are referencing current data.
    2. The provider list will open in a spreadsheet format. Confirm the provider is listed on spreadsheet, which indicates that the provider is enrolled with Medicaid.
      • Click here for instructions on using the Find feature within the spreadsheet to easily search for the physician.
    3. If the provider is not listed in the spreadsheet, the provider is not Medicaid-enrolled. In this case:
        • Review the payer selection to ensure a Medicaid or Managed Medicaid payer is not set up as PRIMARY, SECONDARY or TERTIARY.
        • If there is a Medicaid or Managed Medicaid payer set up as PRIMARY, SECONDARY or TERTIARY, notify the branch that the provider is not Medicaid-enrolled. Ask the branch whether they would like to proceed or not (knowing they cannot bill a Medicaid payer if they use this provider).
  6. Next, send email communication to the requestor, branch Intake team, Clinical Supervisor and the Clinical Intake Coordinator, using this template below:
    • If the Clinical Intake Coordinator is out of office, instead add the Compliance Manager.

TEMPLATE

In the subject line of the email:  Request to Add Out-of-State Provider: Client ____ _____

In the body of the email:

Provider _____  _________ is licensed only in the state of ___________.   As the provider is not licensed in Minnesota, additional steps are needed to determine whether this provider can be used for this client, ________ ______.

Branch- please reply all including your responses to the questions below, specific to this client.

  1. Has the appropriate Branch Clinical Team been notified, i.e. Clinical Supervisor (existing client), Area Manager (new referral), etc.?
  2. What are the ordered services and payer sources for the client?
  3. Is the provider a VA Provider?
  4. Is the client receiving services under the VA benefit?
  5. What is the primary and any secondary payer involved?
  6. Has the out-of-state provider examined (had a physical visit with) the client in the state he/she is licensed in?
  7. Did the out-of-state provider write the order in the state they are licensed in?
  8. Did the out-of-state provider complete the clinical encounter note for the F2F?
  9. What is the long term plan for home care orders?
    • Does the out-of-state provider plan to follow the client’s plan of care from out-of-state or hand off the care of the client to another provider within the state of MN?
    • If the provider is handing over care, when is the visit with the MN provider scheduled for?
  1. Next, in HCHB, update the Follow-Up section of the REQUEST TO ADD A NEW PHYSICIAN coordination note, stating that the process to evaluate the out of state provider has been initiated and an email sent to the branch.
  2. The branch location will obtain all necessary information and reply back to the Request to Add Out of State Provider e-mail with responses to the above items for approval. The Clinical Intake Coordinator (or Compliance Manager) must be included on the response.
  3. The Clinical Intake Coordinator (or Compliance Manager in their absence) will determine whether the out-of-state provider can be used in this case, which is specific to the client, following C-11-917 Evaluate Out-of-State Provider Requests. They will then respond back to the Branch location and Medical Records Specialist with the final determination and guidance moving forward.
  4. If approved, complete C-14-213 Review Request to Add New Physician and enter provider into HCHB.
  5. In HCHB, in the provider's information, identify the provider as being licensed out-of-state by adding the physician group Out of State License to the provider's information, overriding the physician group specific to the clinic group (e.g. Allina).
  6. After completion of all previous steps, notify the following individuals:
    • Compliance Manager, who will add the specific provider and client information into a tracking system
    • Medical Records Specialist who is assigned to adding provider group tags in Mosai, who will identify the provider as being licensed out-of-state in Mosai by adding the directory tag Out of State License to the directory.

📅 Effective: 03.25.2024  | 🛠️ Revised: 08.24.2026 |  ✅ Approved: JFJ

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